the appropriate use of closed circuit television (cctv...

The Appropriate Use of

Closed Circuit Television (CCTV) Observation

in a Secure Unit

Dr Jerry Warr

Mathew Page

Holly Crossen-White

July 2005

ISBN: 1-85899-184-6

© Institute of Health and Community Studies

Bournemouth University

The appropriate use of Closed Circuit Television (CCTV) observation in a secure unit

2

Acknowledgements

This research study was undertaken by the following individuals:

• Dr Jerry Warr, Reader in Practice Development, IHCS, Bournemouth

University;

• Mathew Page, Senior Charge Nurse, Montpelier Unit, Gloucester;

• Holly Crossen-White, Research Fellow, IHCS, Bournemouth

University.

The project was completed within the Centre for Practice Development at

the Institute of Health and Community Studies at Bournemouth

University.

Our thanks go to Calum Meiklejohn, Unit Manager at the Montpelier Unit,

for commissioning the study, and to Roland Dix, Nurse Consultant, for his

support.

The study was funded by Gloucestershire Partnership NHS Trust.

We are grateful for the help and support of the staff and patients of the

Montpelier Unit in contributing to this study.

Some of this study was undertaken as part of an MSc in Psychiatry

(Forensic Studies) at the University of Birmingham by Mathew Page,

supervised by Dr Warr.


3

Contents

Page

Executive Summary …………………………………………… 5

Introduction ……………………………………………………...

Background ……………………………………………

The study ………………………………………………

7

7

8

Literature Review ……………………………………………….

Effects of observation ………………………………...

Policy and practice ……………………………………

Questions arising from the review …………………..

11

11

12

13

The Study ……………………………………………………….

Preparations for the use of CCTV …………………..

15

15

Methodology …………………………………………………….

Project timetable ………………………………………

Data collection ………………………………………...

17

18

18

Findings ………………………………………………………….

Documentary evidence: Reported incidents ……….

Qualitative evidence: Interviews with staff …………

Qualitative evidence: Interviews with patients ……..

21

21

21

29

Discussion …………………………………………………........

Principles of observation ……………………………..

Issues arising from the study ………………………..

34

34

34

Conclusions ……………………………………………………..

Summary of findings ………………………………….

Overall conclusion …………………………………….

37

37

38

Recommendations ……………………………………………..

Improvements to the current system for the use of

CCTV …………………………………………………..

Methods for taking the research forward …………..

39

39

40

References ……………………………………………………... 42

Appendices

1. Draft guidelines and procedures for patient

observation …………………………………………….

2. Draft care plan for night-time observations ……..

44

47


4


5

Executive Summary

Background to the

research

Observation is a necessary procedure in maintaining the safety of people

with mental health problems in in-patient settings. Traditionally this has

involved the physical actions of a nurse or other care worker to maintain

surveillance.

Improvements in CCTV technology have meant that such observations

are now possible remotely and this was the thinking behind a system

being introduced in a purpose-built low secure unit. The installation of

cameras in bedrooms was seen as a means of reducing night-time

disruption for the patients, but it also raised unforeseen criticisms from an

ethical and rights viewpoint.

Purpose of the study This study sought to address the introduction of the system in an

acceptable and safeguarded manner, while undertaking an evaluation of

some of the impacts. The chosen approach was action research. The

developments comprised:

• Producing protocols for use;

• Staff training in the use of CCTV;

• A review of the literature;

• Explaining to patients and gaining consent for use.

The areas evaluated included:

• A review of the protocols;

• Interviews with patients;

• Interviews with staff;

• An analysis of reported incidents.

The research and development was conducted over an 18-month period

and was subject to approval from the Local Research Ethics Committee.

Findings • Some errors had been made in the early stages of the project;

• Training was essential to ensure appropriate use;

• Protocols are important to ensure compliance;

• The system is not seen as more ethically problematic;

• It did not appear to produce incidents or paranoia;

• Staff saw many therapeutic advantages;

• Patients saw security advantages and less disruption;

• It does not have the potential to reduce staffing numbers;

• There is greater potential for less restricted use.


6

Conclusion

Overall, the study did not identify problematic areas that are not also

associated with traditional observation methods. By offering it as an

option to patients it negates any real benefits of its use.

Recommendations

• Safeguards in the shape of protocols and training are vital;

• If it is to be a therapeutic intervention, it should be prescribed on an

individual basis;

• Offering options does not give benefits beyond convenience;

• It is observation itself that requires researching.


7

Introduction

Background

There is no doubt that since the first hospitals were developed for treating

the mentally ill the process of maintaining safety has been problematic.

Incarcerating people who are actively trying to harm themselves or other

people is fraught with obvious difficulties. The practice of what has

become known as ‘nursing observation’ developed for this group. In

modern times, nursing observation is used as a therapeutic intervention

and is now generally undertaken according to a policy suggesting that a

patient is placed on a certain level of observation according to the level of

risk they pose. Levels vary from immediate proximity to occasional

checking of whereabouts.

Observation

This practice of observation is necessarily intrusive. It involves the

removal of privacy and associated dignity, and individuals are expected

to tolerate a constant disregard for their autonomy.

In recent years, academic debate has occurred over whether

observations are still necessary in a well-resourced facility with well-

trained staff. Authors such as Barker and Cutcliffe (1999) advocate an

alternative approach that relies on engagement. At its basic level,

observation seems to provide safety but little else.

Despite this debate, observation appears to continue to be one of the

most common interventions in in-patient mental health care (Porter et al.

1998; Bowers et al. 2000; Meiklejohn et al. 2003). The local policy of in-

patient units (Gloucester Mental Health Partnership 2002) requires

patients to be attributed a level of observation concordant with risk

assessment.

Use of CCTV

It was with this in mind that the project commissioning team for the

Montpellier Low Secure Unit requested that infra-red closed circuit

television be incorporated into the design of the new unit. Each of the 12

bedrooms was fitted with an infra-red camera hard wired to a monitor in

the main office.

The cameras were each fitted with a sensitive audio facility, which easily

detects the breathing of most people while they are asleep. The benefit of

infra-red light is that there does not need to be any visible light in the

room for observation. The monitor is positioned in the office so that only

members of staff can see it. The images and sound are not recorded.


8

Long before the unit was opened, the presence of this system proved to

be highly contentious and it became the subject of considerable criticism

and occasional ridicule - the new building was nicknamed the ‘Big

Brother House’ in reference to the popular Channel 4 television

programme. The logic of the system was apparent to the commissioners

and managers; however the only way to answer many of the questions

raised was to subject it to rigorous evaluation.

The system was installed with the intention of making the practice of

observation less disruptive to its subjects, but it was important to

recognise that such a system could be problematic. Prior to opening,

discussions with in-patients, as documented by Dix (2001), gave a

favourable reception to the notion of using electronic means to make

observation less disruptive. More recently, in focus groups conducted by

Dimery et al. (2003) on the issue of observation, patients suggested that

CCTV should be used more.

It is thought that there are probably a number of CCTV systems installed

in wards around the UK that have not been evaluated. Anecdotal

evidence suggests that CCTV is already being used for observation, but

there has been no academic reporting.

The Study

Context of the study

Montpelier Unit is a brand new, purpose-built, low secure in-patient

mental health unit, which received its first patients in February 2003. Low

secure units are now a common feature within many NHS Trusts and

their aim is to:

…provide expert, supportive, individualised care for those

whose psychiatric condition requires treatment in conditions of

security. The service will be provided by a multi-disciplinary

team which will have a therapeutic focus on rehabilitation and

social inclusion. Every patient’s clinical management will depend

upon thorough and continuous assessment of risk. (Gloucester

Mental Health Partnership 2002, p1)

Perceived benefits

of CCTV

Part of the assessment strategy was the inclusion of closed circuit

television cameras with infra-red facilities and videoing capabilities in the

design of the building. This technology has the potential to enable 24-

hour surveillance of patients in all areas of the unit including bedrooms.

Such an approach could be viewed as a positive response to Standard 7

of the National Service Framework for Mental Health (DoH 1999a), and

the Suicide Prevention Strategy for England (DoH 2002), in that constant


9

surveillance of vulnerable patients would be possible. It also complies

with the need for ‘regular night-time observation’ identified in the report

Safe Supportive Observation (DoH 1999b). The following advantages

have been suggested by Dix (2001) for the use of infra-red CCTV

surveillance:

• No need for an interior light in the room as would be necessary for

observation through a door mounted panel;

• Greatly diminished risk of one patient being able to look in on

another as is common with a door mounted louver panel;

• No need for members of staff to enter the room to make

observations;

• A clear image of the individual resulting from infra-red illumination.

Potential problems

of using CCTV

Such perceived advantages need to be considered in relation to the

potentially negative effects of remote surveillance. Newman and Hayman

(2002, p179) describe the technology as ‘Janus-faced’ in trials in police

cells, in that ‘thought needs to be given to how the tension between the

protection (of suspects) and their right to privacy can be reconciled’.

Indeed, Dix (2001) identified possible complications in the use of infra-red

cameras:

• An infringement of the human rights of the individual being observed

with regard to the right to privacy;

• Ethical considerations, in terms of the justification of this means of

monitoring;

• The protection of data collected on individuals by this means

(Regulations of Investigatory Powers Act 2000);

• Practical implications for using this approach and its ramifications for

nursing practice;

• Possible negative effects on the patient’s mental state.

Little research has been conducted into the use of this form of

surveillance in mental health care.

Need for study Against this uncertainty, the lead applicant was approached by the unit

manager of the Montpelier Unit, with the support of the medical

consultant and the consultant nurse, to discuss a possible proposal to

both develop the appropriate use of CCTV technology and evaluate the

issues involved.

Purpose of the

research study

It was felt that the study should examine whether or not the use of CCTV

observation has a role in the management and care of patients in a low

secure mental health in-patient unit. The technology was already installed

in the Montpelier Unit but there was little guidance, locally, nationally or

internationally, for its use in a therapeutic setting. It was important,


10

therefore, that the study involved the staff and patients of the unit in

developing protocols for CCTV use and evaluating its effectiveness and

acceptability. It was hoped that the findings of the research might help to

inform policy and procedure for CCTV observation in other health care

settings.

From an initial review of the published literature, the protocols, training

and procedures were established and evaluations undertaken from a

range of perspectives.


11

Literature Review

The current literature on observation appears to fall into two groups. A

few authors concentrate on the effects of observation on patients but,

more commonly, papers seem to review policy and practice.

Effects of Observation

Constant

observation

There is an emphasis on the effects of constant observation (Ashaye et

al. 1997; Cardell and Pitula 1999; Fletcher 1999; Jones et al. 2000) but

little on the effects of intermittent observation such as that practised via

CCTV. The issues associated with these two types of observation are

markedly separate. Most of the themes reported by respondents reflect

the necessity of a nurse being present at all times, such as when using

the toilet (Bowles et al. 2002). Some, but not all, findings of research into

this practice may be applied to intermittent observation. For instance,

Cardell and Pitula (1999) identify both positive and negative effects of

observation. Positive effects include the sense of support experienced by

individuals being observed, which may also apply to intermittent as well

as constant observation. One feature of the proposed CCTV research

should therefore be to establish whether recipients of the new form of

observation feel less supported than when traditional methods are used.

In the same research project, non-therapeutic effects included patients

feeling that observers were remote and not empathetic, and that they

were not given sufficient information as to the purpose of the process.

A study of patients’ experience of constant observation by Ashaye et al.

(1997) found that patients felt they had not received enough information

about observation. Jones et al. (2000) also identify this problem.

Effects on behaviour

Outside of the healthcare literature, a criminological research project by

Short and Ditton (1998) evaluated the effects of CCTV on offenders

through interview. They found that respondents were knowledgeable

about the CCTV and that they displayed a wide variety of attitudes about

its use in crime prevention; some favourable, others not so. Offenders

acknowledged two types of change in behaviour: desisting from offending

and geographical displacement of offending. There is a case for

investigating whether patients subject to CCTV observation describe

either of these phenomena in terms of any kind of behaviour or that it

contributes to problems.


12

Distancing staff and

patients

Rosenhan (1973) reports on an experiment where ‘pseudo patients’

(individuals without mental illness) were admitted to various psychiatric

hospitals in the USA and then recorded their experiences. Despite its

age, the results of this study are enlightening and remain relevant to the

way psychiatric institutions are organised. The pseudo patients noted that

staff and patients were strictly segregated, each having their own areas.

Staff would gather in the office and only emerge for care-giving duties. It

would be beneficial to establish whether or not patients feel that the use

of CCTV observation adds to a sense of segregation.

Policy and Practice

Disciplinary

application

Foucault (1975) conducted a philosophical discourse into the history of

the prison. Along the way, he addressed some ideas that remain relevant

to modern psychiatry. He discussed the development of several types of

institution and how these are mirrored in punitive environments, noting

that hospitals began to be organised as instruments of medical action, to

allow better observation and ensure the best calibration of treatment.

Meanwhile, he assumes that disciplinary environments function as a

microscope on conduct, creating fine analytical divisions within the

apparatus of observation. In the perfect environment, a single gaze would

see everything constantly. This leads on to his description of the

panopticon.

The panopticon

The panopticon is an architectural construction reflecting the ideas

outlined above. From a central tower, an attendant can look through

windows into a ring of cells around the central pillar. It is lit so that

inmates can be seen from the tower, but they cannot see in. Foucault

concludes that all types of inmate can be adequately observed in this

way, the most significant effect being that permanent visibility ensures

power. For this to be effective, the inmates must never know whether or

not they are being observed.

The function of the panopticon may be assumed by anyone, regardless

of rank or status, and motivation is also irrelevant, be it curiosity, malice

or perversity.

Disempowerment

The concept of panopticism may well be relevant to institutional

psychiatry and the practice of observation. No doubt most would argue

that one of the main functions of observation is to ensure that treatment

can be correctly calibrated. However, themes discussed by both Foucault

(1975) and Rosenhan (1973) revolve around the notion of power in

psychiatry. Within secure care, this may be even more obvious as

individual liberty is greatly infringed upon. The practice of nursing


13

observation, whether intentionally considering Foucault’s arguments or

not, is likely to disempower a group who are often already

disenfranchised by society. Without doubt, the provision of CCTV for

observation is one step closer to panopticism than most modern

psychiatric wards. The ability to observe everyone with ‘a single gaze’ is

more achievable with CCTV than when corridors have to be walked down

and windows looked through. It is perhaps more reflective of wards 30

years ago where patients slept in dormitories and could be easily viewed.

Consequently, providing CCTV for observation could be seen as a

technological panopticon, with all the associated risks and benefits this

brings.

Use of CCTV in care

Little research has been conducted into the use of this form of

surveillance in mental health care. In the United States of America, the

Florida Medical Directors’ Association has recommended that the

technology should not be used in nursing homes in Florida as ‘it will do

nothing but harm the relationship between patient and caregiver and they

should not be used in bedrooms’, despite a ruling in favour of their use by

the Joint Attorney General for Health Care Administration. In the United

Kingdom, the Royal College of Psychiatrists emphasised the need for

informed consent to be given by the patient who is being recorded, and

stressed that surveillance for investigative purposes raises ‘particular

ethical issues’ (Royal College of Psychiatrists 1998).

Questions Arising from the Review

Areas from the literature that were thought to require addressing in the

study include:

• How does CCTV observation compare with traditional methods?

• How do patients feel about the use of CCTV observation?

• How do staff feel about using CCTV for observation of patients?

• Does the presence of CCTV make it less likely that patients will harm

themselves or anyone else?

• Does the presence of CCTV in bedrooms raise further ethical

questions?

• Does the use of CCTV add to a sense of segregation between staff

and patients?

• What safeguards need to be considered with the use of CCTV?

The need to evaluate the use of new initiatives is well founded in the

principle of practice development. Patients should be involved as much

as staff in this process and an action research model allows for this

involvement in the design, implementation and evaluation of a proposed

change in practice (Greenwood 1984).


14

The process should facilitate the achievement of:

• Improvement of a practice of some kind;

• Improvement of the understanding of a practice;

• Improvement of the situation in which the practice takes place (Carr

& Kemmis 1986, p165).


15

The Study

Preparations for the Use of CCTV

Development of

protocols for

appropriate use

A working group was established to consider the appropriate use of this

method of observation. The draft guidelines and procedures devised by

the working group (see Appendices 1 & 2) were then reviewed by the

whole team. Revisions were made to the draft documents in light of the

comments received.

The documentation derived from this process had three purposes. It

provided a policy document for the unit, formed the basis for training, and

offered clarification on how to explain to patients about the CCTV facility

available on the unit and their choice about consenting to its use.

The structure of the draft protocol drew on published evidence and

considered the following:

• A clear statement on the purpose of observation;

• An outline procedure commencing on admission;

• Levels of observation;

• Relationship to the care plan;

• Use of CCTV or traditional observation at night;

• Gaining consent for CCTV use and a draft care plan.

Review of the

protocol developed

The initial protocol was clear in relation to the mechanics of undertaking

observations and securing consent but it did not consider the issues

related to best practice. Particular aspects that could have been

addressed involve:

• The differences (and potential differences) associated with remote

observation compared with traditional methods;

• Potential for misuse of CCTV;

• Potential for unacceptable use of CCTV.

The assumption made within the document was that CCTV was a

variation on traditional observation and, as such, could be considered

jointly in a single protocol.

The implicit view was that the use of CCTV was desirable on the basis

that it would be a less disruptive approach for patients. The guidelines

failed to explore this standpoint or evaluate particular therapeutic

situations and the use of CCTV. Consequently, the opportunity to

improve its therapeutic application for some mental health patients, or

indeed to recognise that there may be circumstances when the use of


16

CCTV could have negative outcomes, was overlooked. The subsequent

research reveals that CCTV needs to be considered as a distinct

approach and that its operating characteristics and potential should be

outlined in separate procedures and protocols.


17

Methodology

The approach to the study was through an action learning framework to

allow for the development of CCTV procedures while using concurrent data

collection to provide a comprehensive evaluation.

Research question

There were two aspects to the study and these are reflected in the

following research question:

What is acceptable use of CCTV surveillance in a secure mental health in-

patient unit and does it benefit patient care?

Study objectives

The objectives for the study can be categorised into two specific areas:

improving operational understanding and developing appropriate

practice.

Improving operational understanding:

• To trial the use of the technology to establish its benefits and

limitations;

• To evaluate the acceptability of CCTV surveillance to patients;

• To evaluate the acceptability of CCTV surveillance to mental health

practitioners;

• To consider the effects on skill usage;

• To identify areas for further consideration and research.

Developing appropriate practice:

• To develop protocols for acceptable usage with reference to the

perceived benefits and effects on privacy, the law and therapeutic

relationships;

• To produce safeguards for ethical use of the technology;

• To identify areas for skill development;

• To develop ‘best practice’ guidelines where the technology is

employed.

Sources of evidence The process of analysis drew on three data sources, combining

documentary evidence and qualitative data. The sources were:

• Reported ‘untoward’ incidents on the unit over a 12-month period;

• Interviews with staff within the unit (n=10);

• Interviews with patients from the unit (n=6).


18

Project Timetable

Ethical approval from the Local Research Ethics Committee was sought

prior to the commencement of the study. The progress of the research is

summarised below:

May 2003: Initial meeting of the action research team. Identification of issues and

problems/strategy planning.

June 2003 – January 2004:

Action research review: implement and evaluate.

February 2004: Action research review: commence qualitative interviews (patients).

March 2004:

Action research review: commence qualitative interviews (staff).

September 2004:

Action research review: data analysis of staff interviews.

Commence patient interviews.

December 2004:

Action research review: data analysis of patient interviews.

January 2005:

Report writing.

Evaluation of process and outcomes.

March 2005:

Dissemination of results.

Data Collection

The evaluation was structured around documentary material and

qualitative interviews with both staff and patients. The nature of the data

collection process is outlined in the following section.

Documentary

evidence:

Reported ‘untoward’ incidents One measure of change following the introduction of CCTV was

considered to be found in the nature of ‘untoward’ incidents occurring

during the night (defined as when CCTV was in operation).


19

Incidents that occurred were documented, giving details of the date and

time, the patient, the nature of the incident, who else was involved and a

description of the incident. Whether any injuries were sustained was also

noted. It may be difficult to determine whether the presence of CCTV had

a more beneficial effect in such circumstances than traditional

observation methods. Despite this, a review of all incidents occurring at

night was undertaken, and each incident was assessed for any

differences in the nature of events and whether or not the use of CCTV

may have had a contributory role.

Reviewed incidents

In total, 45 incidents were recorded as ‘untoward’ over a 12-month

period, but only eight of these occurred at night (defined as the period

when CCTV cameras were in use) and could therefore be included in the

analysis. All the reported incidents involved verbal or physical abuse on

staff or other patients.

Qualitative evidence: Interview data

The interviews involved both staff and patients from the unit. The

recruitment criteria for participants varied between the two groups of

interviewees. For staff, the requirement was that the individual had

experience of operating CCTV at night. For patients, the criteria were

wider to include any patient on the unit whether using CCTV or not.

Recruitment procedures

Within the unit, potential participants (as defined by the inclusion criteria)

were informed of the study verbally and given a prepared information

sheet about the study, its purpose and what participation would involve.

Those approached were given the opportunity to ask questions and a

period of time to reflect on their decision to participate. Those who

decided to participate were asked to complete a standard consent form.

Prior to the patient interviews, the relevant procedures were undertaken

in terms of a formal application to the appropriate Research Ethics

Committee.

Format of the interviews

The interviews were conducted at the unit by members of the research

team in a private room to ensure confidentiality. With the permission of

participants, the interviews were tape-recorded and later transcribed for

analysis.

The interviews with both staff and patients were structured around the

following areas:


20

• Views on night-time observations generally;

• Interviewees’ experience of the CCTV or, for patients not using

CCTV, why they had not consented to the use of CCTV;

• Interviewees’ impression of the impact that the introduction of CCTV

had on the unit.

Staff sample Ten interviews were undertaken with a cross-section of staff that included

representatives of all nursing grades employed on the unit. All

interviewees had experience of using the CCTV cameras for observation

at night.

Patient sample

Six patient interviews were undertaken. This equated to two-thirds of the

unit’s occupancy. The interviewees were all male, with ages ranging from

21 to 45 years. They all had a primary diagnosis of schizophrenia with

lengthy histories of previous admissions to hospital and penal institutions.

The sample included those being observed by CCTV and those who

were not.

It had been anticipated that interviews with the patients would be more

problematic but in the event this was not the case. However, the data

gathered was more limited in terms of its depth and the extent to which a

considered opinion could be offered. Despite this, the data conveyed a

clear sense of the patients’ views on the use of CCTV within the unit.


21

Findings

Documentary Evidence: Reported Incidents

Reported ‘untoward’

incidents

The analysis showed that there were fewer reported incident during the

night period but this is likely to be the case as most patients are asleep at

this time. However, the nature of the incidents did not differ significantly

from incidents reported during the day and there is nothing in the reports

to suggest any association with:

• The presence or use of CCTV;

• The choice of the patient to be observed using CCTV or not.

Qualitative Evidence: Interviews with Staff

The data collected through interviews with staff are reported below,

structured around the themes identified through content analysis of the

transcripts. These themes are:

• Staff attitudes to CCTV;

• Impact on undertaking observations;

• Benefits to patients;

• Benefits to staff;

• Issues that arose from the use of CCTV.

The interviews indicated that staff responded to the introduction of CCTV

in different ways. Some appeared to be very enthusiastic about it and so

placed great reliance on it for patient observations.

I think it is good. I think it is a good way forward. (I3)

The benefit is that you can see more clearly than actually going

in and disturbing the patient…you can just keep an eye on them

in there. (I5)

You just flick on for a couple of seconds and we know they are

breathing. (I5)

From the point of view of the nurses we can do it all from one

place. (I6)

Other members of staff used CCTV but did not do so exclusively,

choosing to check patients physically at times.


22

I will still, you know, double check anyway throughout the night

shift. I don’t tend to just reply wholly on that [CCTV]. (I2)

A few staff also had reservations about CCTV, feeling that it could not be

relied on and so preferred to undertake physical observations.

Sometimes you don’t really get a very good sort of picture so

you have to go and check anyway. (I2)

You can’t always be entirely convinced that they are OK. So

sometimes it does need to actually go down to their room and

check visually anyway. (I4)

It’s only machines, it’s like on the movies, the picture can get

stuck and you think, ‘Oh they’re still fine…they’re still fine’. I

think it’s good to be aware it’s just machines. (I3)

The interviews therefore offered a good range of opinion on the use of

CCTV. An analysis of the resulting interview transcripts provided a

number of themes:

• Issues relating to undertaking observations generally;

• The benefits of CCTV;

• Issues that arose because of the use of CCTV;

• Changes in practice;

• Ethical issues;

• Improvements to the current system for the use of CCTV.

Undertaking

observations

The interviewees all discussed how the actual process of conducting

observations at night on patients was highly disruptive.

A traditional routine of observing can be quite intrusive…and it

wasn’t very helpful for those people who are quite disturbed and

wanted a good night’s sleep. (I4)

When you’ve got people coming into your room every 15

minutes or half an hour and shining a torch through your door,

it’s very intrusive. (I6)

Several staff pointed out that the disruption caused by undertaking

observations at night had the effect of reducing the amount of sleep the

patient could have. This was particularly unfortunate, as often patients

required more sleep to improve their condition.


23

I think it gives the patient more opportunity to get quality

sleep…They [patients] would hear you coming round at night

and suddenly to get interrupted every hour of their

sleep…obviously it does their mental state…not very good. (I1)

We all need sleep whether we are unwell or mentally stable. We

all need a certain amount of sleep. (I5)

Interviewees reported how the disruption caused by observations at night

could make patients quite irritable and potentially aggressive towards

staff.

…safer for the nurses because you’re not just getting into

altercations with the patients, waking them up. I’ve seen that

quite a lot. (I3)

You know you’re going to wake them. Sometimes you do, and

they get aggressive. (I8)

I’ve had a patient come flying at me doing a manual check. It’s

quite noisy and you disturb them and they complain. (I7)

Providing this context to their perceptions of how effective CCTV was for

observations was useful and provided insight into how the staff would

assess the benefits of the new system. Broadly speaking, the benefits

they outlined fell into two main areas: those they identified as benefiting

the patient and those that aided staff.

Benefits for patients Many of the interviewees spoke about how the use of CCTV enabled

patients to have less disturbed nights because less movement of staff

meant the ward was quieter. CCTV meant they could easily observe a

patient without entering their room and/or waking them. Some of the staff

believed that the CCTV camera in the patient’s bedroom was actually

less intrusive than a member of staff physically entering the patient’s

room.

The difference is it’s a lot quieter. Obviously when you are

walking down the corridor with keys that we collect…obviously

it’s a nightmare…noise travels and it echoes. So it’s a lot

quieter. You’re not disturbing the patient. (I5)

It’s very inconvenient for them, you know, keep waking them up

every hour…but if you have got a camera… (I3)


24

I think it gives the patient more opportunity to get quality sleep

as opposed to going round because they hear us. (I1)

I think it’s [CCTV] probably less intrusive for patients…I suppose

it promotes a better night’s sleep for the patient. (I2)

I think having someone coming into my room every hour would

be more obtrusive than having a little red ring of lights come on.

(I4)

It was highlighted how CCTV could benefit the patients when incidents

occur on the ward that might require most staff to be involved for a period

of time. Such incidents may not leave staff enough time for physical

observations of the other patients, but CCTV means that these

observations can be completed quickly and are therefore more likely to

be done during an incident. Thus, CCTV ensured that the welfare of other

patients was not infringed by any unexpected incident on the ward.

If we’ve got something else going on…and we need to do a

quick check to make sure the other guys are safe…it allows us

to get back to what we were dealing with. (I7)

Several staff also felt that CCTV improved the level of patient

observation.

The benefit is that you can see more clearly than actually going

in and disturbing the patient. (I5)

We can hear if they are breathing and things like that which we

can’t do from outside the door. (I6)

Benefits to staff The staff felt that the use of CCTV offered them a range of benefits,

particularly regarding improving their personal safety. As discussed,

observations at night often made patients irritable and aggressive

towards staff and CCTV helped avoid or reduce these situations.

Furthermore, staff believed that CCTV could help them assess emerging

violent situations with patients because they can observe a patient’s

behaviour without entering the bedroom and putting themselves at risk.

CCTV also offered the potential for one colleague to monitor the safety of

another who had entered a bedroom of an aggressive patient.

That’s obviously quite a vulnerable situation for a member of

staff, knowing full well that that person is quite hostile at that

time. (I4)


25

We can use the cameras as a mode to check the safety of the

staff. (I7)

Several of the staff also identified that CCTV in the patient’s bedroom

gave them the opportunity to assess whether a patient’s behaviour in

communal areas of the ward was truly reflective of their general

behaviour/well-being when alone. This perhaps indicates that some staff

may have been using the CCTV equipment outside the hours stated in

the protocol.

So we’ve been able to get a sort of snapshot picture of people’s

presentation which is very different to their presentation on the

ward on occasions. (I4)

It should be noted that using CCTV in this way was in breach of the

agreed arrangements explained to patients regarding the use of CCTV.

Issues that arose

from the use of

CCTV

Since the introduction of CCTV, various issues emerged for staff. During

the interviews, staff discussed how the system had been refined by the

fitting of new monitors that had enhanced the picture quality and thus the

usefulness of the system to staff. Despite the improved quality of the

monitors, it was apparent from the interviews that physical observation of

patients was still required in some circumstances where the well-being of

the patient could not definitely be established, for example if bedcovers

were obscuring the patient’s face.

If there is no movement in the room, all you are seeing basically

is a lump in the bed and that’s not very satisfactory. You know

you can’t see if anybody’s breathing or not so you have to go

and check physically to make sure everything is OK. (I2)

There was also indication that some staff lacked confidence in using the

equipment and so continued to do physical checks.

In general not many people seem that confident with the

technology…It’s much easier to walk around, listen at door…

(I10)

I’m not sure what I’m seeing on the screen, I still use traditional

methods as well. (I3)

The interviews also highlighted that, even if staff did know how to operate

CCTV and were satisfied with what they saw on the monitor, a few still

felt the need to carry out physical checks at some point during their shift.


26

I don’t know, sometimes you can get more from personally

seeing someone than observing them through the cameras. (I4)

An area of particular note was the response from patients to CCTV. The

take-up among patients seemed to have been lower than anticipated. In

addition, CCTV did seem to have produced a negative affect for some

patients. According to several members of staff, the presence of the

cameras seemed to make some patients more unwell, by increasing their

paranoia.

I’d feel that could make you feel quite paranoid. (I6)

It’s very difficult when you have a certain number of patients on

the ward who’ve got paranoid schizophrenia, for example, who

become very paranoid about the fact that you are using

cameras and observing them. (I4)

In addition, staff described how some patients had been unhappy at the

presence of the cameras, whether they were in use or not. The existence

of the equipment alone made some patients uneasy. Staff reported that

some patients who had cameras in their rooms, but who had not

consented to their use, had attempted to cover up the cameras.

The patients put white paper on [the camera]…I don’t know but

the paper seems to be working…Because they want to be sure

if they haven’t consented they still don’t want that camera

looking at them, cause they won’t know it’s off. (I3)

Some guys who really don’t like them [cameras] being in there

even when they are covered up. (I10)

It seemed the patient’s concerns were partly fuelled by several incidents

that occurred over the period since CCTV was installed. Specifically, the

system had not been fully turned off at the control unit on one occasion

and this meant lights remained illuminated on the cameras leading to

patients believing they were being observed continuously when in fact

they were not.

There was one incident where, like the cameras were left on

instead of being switched off at the wall. They’ve accidentally

been on and the screen had been switched off so no-one was

looking but to all intents and purposes to the patients the red

ring of lights to say it was on had remained on. (I4)


27

However, the interview data did suggest that the cameras had been used

outside the designated night-time periods and this was confirmed by

comments made by one of the interviewees.

When I first started people were still using them throughout the

day. (I10)

Furthermore, on occasions the wrong CCTV camera had been switched

on during observations. With no apparent safeguard in place to put a

block on individual cameras, there is the potential for staff to mistakenly

observe patients via CCTV who had not consented to the use of this

method. This situation would therefore validate the concerns of some

patients about the presence of a camera in their room.

Taken together, the data suggest that the anxiety of patients about the

camera may have been fuelled by two factors: apparent daytime use as

reported by staff at interview and a lack of patient confidence in the staff

about how and when the cameras would be used.

Several staff also suggested that the introduction of cameras meant

patients had less privacy. Use of CCTV had, at times, led some staff to

see things that perhaps they might not otherwise have seen. Attention

was drawn to how the sound of an approaching member of staff, either in

terms of footsteps, voice or opening and closing of doors, meant that

patients had some opportunity to prepare themselves if they wished by

putting on clothing for example. With the introduction of CCTV this

opportunity was lost. Several interviewees reported switching on the

CCTV and seeing patients in circumstances that they would rather have

not seen.

You could be in a situation when you flicked the camera on and

thought ‘Oh I don’t want to see that,’ whereas if you were

observing in the traditional method they’d hear you and maybe

cover up. (I4)

However, another interviewee believed that CCTV was an improvement

in this respect as the member of staff could switch off the monitor and the

patient would be unaware, thus avoiding any embarrassment.

You automatically…quickly turn it off. But at least I think that’s

another good thing about the cameras at least you maintain

your dignity on both sides…So it’s uncomfortable…but it’s better

than walking in. (I3)


28

One member of staff interviewed did indicate that being mindful of the

routine of patients avoided such incidents. Considering this before

switching on the CCTV meant the patient’s privacy was less likely to be

infringed.

…never caught anyone undressing or anything like that. Usually

you know if they’ve been in their room about an hour usually

they’re sorted and I can check them…check them ten minutes

after they’ve gone to bed and you’re likely to catch them

undressing. (I10)

During the course of the interviews, some staff spoke about how the

introduction of CCTV had made them feel more remote from the patient.

They recounted how doing physical observations on patients enabled

them to get a general feel for how things were on the ward in terms of

relationships between patients, or the general mood of particular patients.

You may be going down specifically to see them or check on

them but you notice something else is going on with someone

else. That sort of thing can be missed if you’re sitting in front of

a screen. (I10)

Some also went further in stating that physical observations provided the

patient with an opportunity to engage with a member of staff if they had a

worry or concern.

From the CCTV point of view they look as if they are asleep…so

you take that as sleep as opposed to…if their mental state

wasn’t very good at the minute they could be stood staring at

the wall…We would know at that point that maybe you know

they want a chat…we can intervene. (I1)

I think with the CCTV that it’s colder. When I say colder we were

ensuring that they are alive, that they are breathing, that they

were there, that they were safe. We weren’t intruding on them

but one could say that if they wanted to speak to us they could

come out of their room and talk to us but sometimes when

people are awake or distressed at night, I think perhaps they

wouldn’t do that; that they would just lie there and maybe we

would miss some of those opportunities. (I6)

One interviewee stated how the use of CCTV meant that they were not

always sure who they had observed. This was not an issue that was

discussed by all the interviewees and so may be an area more relevant

to individuals rather than a factor involved in the introduction of CCTV.


29

I sort of feel that I haven’t seen them even though I’ve seen

them…by the end of the shift. I have seen them and I know they

are safe but I feel I haven’t seen them; I haven’t engaged with

the patient, haven’t spoken with the patient. (I6)

A further issue to emerge was how the operation of the CCTV equipment

was easier if you used it regularly and were more familiar with it.

When I come off nights, for a long period [when I come back to

nights] I’m like ‘OK, which is that room and that one,’ but when

you do it regularly on night shift it’s quite easy. (I3)

However, the patient interview data suggested that the ward tended to be

covered at night by a number of bank staff who may be less familiar with

CCTV. From the research evidence it was not clear whether the bank

staff were drawn from the same core group and would therefore be

familiar with the CCTV equipment. If the same bank staff were not used

regularly, there is the potential for errors to be made when using the

equipment. This could either be in terms of incorrect use of the

equipment or lack of experience in carrying out observations by CCTV.

Using the equipment incorrectly could mean either observing the wrong

person or missing out a patient and not observing them at all. The

potential for errors to be made was confirmed by one interviewee who

indicated that there had been some issues relating to the use of bank

staff.

We have a lot of bank staff on night shifts rather than on day

shifts and sometimes they haven’t had the proper induction.

(I10)

Qualitative Evidence: Interviews with Patients

The data collected through interviews with patients is reported below,

structured around the themes identified through content analysis of the

transcripts. These themes are:

• Issues related to patient care;

• Safety on the ward;

• Privacy of patients;

• Information giving about use of CCTV on the ward.

Issues related to

patient care

The main issue cited by four of the six interviewees was that the use of

CCTV meant less noise and less disruption at night.

It helps to save disturbance at night. (P5)


30

The next most cited issue was that the patients perceived a change in the

relationship with their carers in that the use of CCTV reduced the level of

personal contact.

What I like in the mornings is for someone to come in and say

would you like a cup of tea or something. (P4)

R: Is there anything that you dislike about CCTV?

P3: The lack of communication.

Several of the patients also stated a belief that CCTV was beneficial in

particular circumstances rather than general use. For example, CCTV

was considered more appropriate for patients when they were ill.

I suppose you’ve got a camera in the quiet room and that is

probably necessary isn’t it…I think it’s probably necessary, but I

mean if you’re in a reasonably good state of mind and the

nurses don’t think you’re unwell and stuff, then I don’t think you

should watch people with cameras really. (P1)

Another patient found the cameras reassuring when they were taking a

lot of medication.

I think it is a good idea because obviously I am on a lot of

medication at the moment and I certainly don’t want to die in my

sleep from medication and I don’t think the staff would either.

(P6)

One patient who did not wish to have CCTV was concerned that the

presence of CCTV and its use with other patients could mean that staff

might overlook them by not doing traditional observations.

…but when I need help the help doesn’t come. And now I’m

realising that I do need the cameras. (P4)

Another patient highlighted how the presence of the cameras made them

feel less able to relax.

It’s like being in prison or something like that you know. I think

every patient has the right to have time on their own and stuff. If

the cameras are watching you, you really don’t feel you can

relax or anything. (P1)


31

Safety on the ward

Four of the six interviewees expressed views that the presence of CCTV

made the ward a safer place and all offered examples of how they

believed this to be the case. Three of the patients felt that their personal

safety was improved with CCTV.

I feel that having CCTV in the courtyard prevents violence. I

have noticed from other wards there has been a lot of violence

where there have not been cameras. I feel this ward is very

much relaxed, it’s very much relaxed because the cameras are

there no-one is actually going to strike at you without being

observed by the staff. (P6)

Several interviewees thought that CCTV deterred others from breaking

certain rules, which generally made things safer. For example, patients

were less likely to try and smoke in their bedrooms because they could

be observed. Therefore, the risk of a fire starting was reduced.

…and it stops people from causing fires, people don’t smoke in

their rooms much because the camera’s on them. (P3)

…and the other thing, fire risk, I suppose. (P6)

A further aspect of improved safety on the ward related to security of

personal property.

I know that no-one is going to steal anything out of my room.

(P6)

Keeps my items safe. (P5)

When it was explained to one of the patients that the CCTV was only on

for specific periods, not all the time, their view was that the cameras

should be used 24 hours a day.

Privacy of patients

One patient spoke of how the cameras were an invasion of their privacy

because their camera had come on when they were naked. The patient

felt that, in this instance, it was inappropriate for the camera to remain on.

A patient who had chosen not to have CCTV expressed the view that the

use of cameras was ‘just a bit intrusive’ (P1).

Another patient felt that the cameras infringed their privacy at particular

times and that patients should have the right to ask for the camera to be

switched off for short periods.


32

I think they [patients] should have the right to ask for the

cameras to be switched off for privacy and obviously the ward is

all lads and young lads and you know certain, as you know what

lads do, basically it can be embarrassing in the sense that you

know. (P6)

One patient felt that CCTV was more intrusive than the traditional method

of observation:

P1: I mean it’s OK [traditional method] because they are outside

the room, you know, they don’t sort of come in and shine

torches in your face or anything, you know.

R: So you think it might feel more intrusive because the

camera’s in the room then?

P1: I think so; I mean your room is your personal space.

One patient (P6) did seem to become more comfortable with the use of

CCTV as they got to know the staff.

I used to think, ‘Oh God I’m being watched in my room all the

time,’ but now it’s like you said confidential and that’s fine by

me. I know all the staff, they’re great people. (P6)

However, one patient did state that CCTV was a much better method of

observation as they felt less conscious of being monitored.

It’s a lot better…‘cause you don’t get so many people coming

and looking through your door window. (P3)

Information-giving

about use of CCTV

on the ward

The interviews showed that information-giving around the use of CCTV

could be improved. The comments of a number of the patients suggested

that most believed the cameras were in use all the time rather than being

switched on and off periodically throughout the night.

Interview data also indicated that patients thought the cameras recorded

what was seen. This is supported by the patients’ views that CCTV

improved personal safety and the security of property. Implicit in these

statements is the view that cameras are in operation all the time,

including during the day, otherwise the patients would not be so assured

of improved safety. Several of the patients explicitly refer to the cameras

recording incidents.

P3: …‘cause sometimes I’m naked.

R: OK, so you think sometimes…


33

P3: I can see the camera’s on

R: So you are concerned people might be looking at you?

P3: Yeah, recording, I don’t know just recording.

Again the comments below from another interviewee show an implicit

belief that CCTV records when in operation. In this example, the

interviewee talks of how accounts of incidents could be verified

afterwards using footage from the cameras.

Also it allows staff to see what’s actually happening in that room

at the time so if there is an incident and the staff made untruths,

basically the staff will be able to look at those cameras to see if

the actual facts are correct which goes in my favour very much.

(P6)

The assumption that the camera would be on when the theoretical

incident occurs also suggests that the patient believes the cameras are

generally on.

One further issue identified was that the illumination of the infra-red light

on the camera does not necessarily mean that the person in the room is

being observed as cameras cannot be switched on individually, only

collectively, and the pictures from all the cameras cannot be observed at

once. The interview data suggest that patients believed that if the infra-

red light was on, they were being observed. This may be an issue that

requires clarification with patients, given that the infra-red light may

remain on for some time while each of the patients is observed in turn.

For the patients, seeing their camera light on would indicate that they

were actually being viewed for a much longer time than the brief period of

observation.


34

Discussion

Principles of Observation

Observation of people with mental health problems derives from three

basic principles:

• Policy of prevention;

• A duty of care;

• Therapeutic endeavour.

Advances in technology often offer the opportunity to reduce the burden

of human effort while making improvements to the previous methods of

doing things. Therefore, in many industrial settings, new technology can

improve productivity while reducing the number of people required to

carry out activities.

However, mental health care as presently constructed does not equate to

an industrial model. Instead, its effectiveness is based on the interaction

of one human with another and, historically, the profession has been

resistant to making use of impersonal methods of observation and care

delivery. The incorporation of remote systems of observing could be seen

as contrary to the philosophy of an interactive model of care. Indeed,

many of the initial concerns (and the impetus for this study) were

provoked by the alien nature of an apparent ‘big brother’ method of

surveillance.

In fact, the research findings demonstrated that the technology was

viewed as a means to improve patient care in two specific areas:

• To promote the comfort of the patients through reduced disturbance

at night;

• To improve monitoring of patient safety.

Issues Arising from the Study

The use of CCTV in

patient observations

The system is welcomed by the staff as an addition to previous ways of

working but is definitely not viewed as a complete replacement for the

traditional methods. Staff identified particular situations where the

application of the new technology would both be helpful to them and

beneficial to patients. For example, during incidents where a number of

staff may be involved and, as a result, the traditional observations may

be delayed. The use of CCTV here offers the opportunity for one member

of staff to undertake observation of the other patients more quickly

because they can be done from a central point and enhances the


35

likelihood of the task being completed at the specified time, an outcome

which is beneficial to the other patients.

Interestingly, both staff and patients shared the view that CCTV could not

become a replacement for traditional methods of observation. Both

groups expressed the opinion that traditional observation had other

benefits beyond the intended purpose of ensuring a patient had not come

to any harm. These included:

• Opportunities to informally discuss issues of concern before they

become more serious;

• General reassurance of being ‘looked after’;

• Instilling a feeling that help is near by.

CCTV, by its remote nature, cannot replicate these outcomes and this

probably explains why some staff members felt that, when using CCTV,

there was a certain lack of reality to what they were doing. Some staff

reported needing to go and physically check on some occasions to

reassure themselves about what they had observed on CCTV. This could

of course also be a reflection of a lack of confidence in either their ability

to use the equipment or in CCTV itself.

Operation of CCTV The introduction of CCTV to the unit also brought with it new training and

development needs beyond that of therapeutic skills. Effective use of the

equipment could only be achieved when the staff felt confident in

operating it. Several interviewees expressed uncertainty on occasions

about whether they were viewing the correct patient and these anxieties

were heightened when they had not been regularly operating the

equipment for a while e.g. on returning to night shift.

Interestingly, some patients told how they lacked confidence in the way

staff operated the CCTV, mainly relating to times of use (there were

indications that staff had made such errors). However, this would indicate

that greater patient confidence in the ability of staff to operate the

equipment correctly may have an impact on the take-up of CCTV.

Some patients interviewed were also uncertain about the operation of

CCTV in general. This may be another area that could be improved to

make the patients more confident about the use of CCTV on the unit.

Identification of

CCTV with

therapeutic patients

Patients did not acknowledge CCTV as being a therapeutic intervention.

Some recognised it as a way of monitoring them when extra care was

needed, for example when they were on higher levels of medication. A

greater number saw CCTV as a way to enable a more secure

environment in terms of rule-breaking, petty theft or assault, much as a

member of the general public would view CCTV on their street.


36

If the patients’ view of CCTV is primarily as an enhancement to the

security of their environment then it is reasonable to compare their

decision-making with that of the general public’s views about the use of

CCTV as a crime prevention strategy. Some members of the community

oppose CCTV either because they do not perceive a threat to themselves

or would not wish their movements, no matter how innocent, to be

observed using CCTV.

The patients’ preoccupation with safety and security is also to be

expected given the purpose of their hospitalisation, but their lack of

therapeutic association is interesting. Also of interest is the fact that none

of the patients saw the use of CCTV as an erosion or further infringement

of their liberty. This is probably a reflection of their acceptance of their

current situation.

In terms of staff views on the therapeutic use of CCTV, the absence of

much comment during interview must be seen in relation to how CCTV

was implemented within the unit. At the outset, attention was given to the

fact that CCTV was:

• Impersonal;

• More intrusive as a constant feature within a bedroom;

• Did not naturally draw on learned human skills of interaction;

• Open to abuse by staff.

In addition, the protocols and training subsumed its use within the

necessity of observation in general. As a result, the opportunity to explore

the potential of CCTV observation as a therapeutic intervention was

neglected.

However, the interview data did show that staff identified situations where

CCTV has the potential to enhance care and management. Also, some

staff expressed their frustration about the decision of particular patients

not to consent to the use of CCTV as they believed these patients might

have been better observed with the use of such technology.

Ethical issues During the course of the interviews, certain ethical issues emerged.

CCTV enabled staff to witness more than they may have done before

and this presented an ethical dilemma as to how they should respond.

The scale of these incidents varied, ranging from a misdemeanour such

as patients smoking in their room (which is not permitted), to a more

serious incident such as witnessing an assault that would not otherwise

have been seen. To assist staff, guidelines to ensure consistency in

dealing with such incidents would be useful. Such guidance should also

be made available to patients.


37

Conclusion

Summary of Findings

Use of CCTV • The use of CCTV is not a replacement for traditional methods of

observation.

• The use of CCTV is an effective, complementary approach to

traditional observation methods, and would appear to have specific

beneficial applications.

• The study did not find particular difficulties with the use of cameras in

rooms as might have been expected.

• The use of CCTV at night did not have a measurable effect on

‘untoward’ behaviour either in a positive or negative manner. The

ability to observe an incident by camera before it became more

serious is a possibility but this is not generally confirmed in the

subsequent interview data.

Patient perceptions • CCTV was valued by the patients who chose it as a less intrusive

night-time option.

• There was some indication that the greater the confidence of the

patients in the ability of staff to efficiently operate the CCTV may

have an impact on take-up by patients.

• Many patients associated the use of CCTV with the security of their

environment, for example reducing rule breaking, petty theft or

enhancing personal safety, rather than an intervention to assess

their state of well-being during the night.

• Some of the patients demonstrated that they were unsure of how

CCTV was operated. This indicates an area for further work.

Emerging issues • The issues that emerged were around observation and surveillance

per se and are thus beyond the scope of this study.

• Some staff felt less confident about operating the CCTV equipment if

they did not use it regularly. Therefore, refresher training may be an

appropriate option to offer staff on returning to nightshift.


38

• Greater association of CCTV with therapeutic purpose and the

identification of appropriate applications would enhance the potential

outcomes of this method of intervention.

• There is a need to give further consideration to ethical issues, some

of which were unforeseen and relate to witnessing activities that

would not otherwise have been observed by staff had they not been

operating the CCTV.

Overall Conclusion

To conclude, CCTV observation has no major objectionable features

compared with conventional observation and only really has significant

advantages if it is used as a prescribed intervention to best suit individual

observational needs.


39

Recommendations

Improvements to the current system for the use of CCTV

The interviews highlighted a number of issues where improvements could

be made to the operation of the CCTV. These improvements can be

grouped into three areas: technical, operational and ethical.

Technical To reduce the concerns of patients not consenting to the use of CCTV

but who still have a camera in their room, it might be advisable to look at

ways of making the cameras clearly inoperable. This could include the

possibility of temporarily removing the camera or providing a means of

covering the camera, such as a wooden casing that could be placed over

the area where it is located.

The location of the CCTV monitors may also be another issue to consider

in terms of monitors being visible to individuals other than the staff

authorised to view them.

Operational

It would appear that occasionally the wrong camera was switched on,

leading to staff mistakenly observing the wrong person. This could be

overcome by improved labelling of camera switches with the relevant

patient name to ensure that those patients who have not consented do

not have their privacy infringed, and that those who have consented are

observed when they should be and do not get overlooked.

The operation of the camera appears to present some difficulties for staff

and several suggested that greater familiarity through regular use

improves their ability to operate the CCTV effectively. Therefore, every

effort should be made to ensure that particular members of staff with

experience of using CCTV are regularly on duty at night.

Ethical Possibly the largest area for review is in relation to ethical issues. These

can be broken down into specific areas:

• Management of the consent process;

• Staff training;

• Guidance on specific incidents relating to the use of CCTV;

• Patient information.

In terms of the management of the consent process, the main area is

ensuring that everyone who has consented is known to staff and that the

appropriate camera in the office is clearly identifiable. Any changes


40

regarding the consent given by patients needs to be effectively

communicated to all staff, possibly through a list of current CCTV patients

being displayed in the control room with any changes visibly highlighted.

All staff need to receive training on the use of the cameras, the consent

process and how subsequent changes might be notified. Staff who have

not been on a night shift for a period of time should receive a refresher

briefing before re-starting nights.

Training should also include instruction on when and how the cameras

are to be used. This should take into account advice that might help

avoid observing patients perhaps when they are undressed. For

example, CCTV should not be used for 30 minutes after the patient goes

to bed to allow them the privacy to settle down for the night.

Given the range of ethical considerations highlighted in the interviews,

there would seem to be a need for consideration of these issues and

guidance on specific incidents relating to the use of CCTV. This would be

helpful in supporting both staff and patients. Particular areas of note are

observing patients engaged in an activity not permitted on the ward or

where CCTV has enabled staff to witness situations they would not

otherwise have seen. This would include aggressive/violent situations or

any incident where the images seen on CCTV could be used against the

patient.

Information needs to be given to the patients to reflect the issues noted

above, thus enabling consent to be fully informed.

Methods for taking the research forward

The stated aim of this proposed study was to determine the appropriate

use of CCTV surveillance in a mental health in-patient unit. Through the

chosen approach, a variety of reports, protocols and guidance materials

were generated and are therefore available to other practitioners facing

the same dilemmas. The full report has been discussed with the team

and has influenced practice development. The team has gained

pragmatic understanding of ‘research in action’ and working together,

which should produce future benefits for the unit. Additional areas for

research and development have emerged from the process. The action

research approach provided a documentary account of the issues,

problems, solutions and evaluations explored. This means that others

can reconsider the issues in relation to their practice without having to

replicate the processes. The issues, process of exploration and findings

have been widely disseminated and offered for policy development.


41

Examples include:

• Professional mental health journals;

• Open websites;

• Prison health care;

• User groups;

• Conference presentations.


42

References

ASHAYE O, IKKOS G, RIGBY E. (1997) Study of effects of constant

observation of psychiatric in-patients Psychiatric Bulletin 21, 145-147.

BARKER P & CUTCLIFFE J. (1999) Clinical risk a need for engagement

not observation. Mental Health Practice 2 (8), 8-12.

BOWERS L, GOURNAY K, DUFFY D. (2000) Suicide and self-harm in

in-patient psychiatric units: a national survey of observation policies.

Journal of Advanced Nursing 32 (2), 437-444.

BOWLES N, DODDS P & HACKNEY D. (2002) Formal observations and

engagement: a discussion paper. Journal of Psychiatric and Mental

Health Nursing 9, 255-260.

CARDELL R & PITULA CR. (1999) Suicidal in-patients’ perceptions of

therapeutic and non-therapeutic aspects of constant observation.

Psychiatric Services 50 (8), 1066-1070.

CARR W & KEMMIS S. (1986) Becoming Critical. London: Falmer.

DEPARTMENT OF HEALTH (DoH). (1999a) National Service

Framework for Mental Health. London: DoH.

DEPARTMENT OF HEALTH (DoH). (1999b) Safe and Supportive

Observation of Patients at Risk. London: DoH.

DEPARTMENT OF HEALTH (DoH). (2002) Suicide Prevention Strategy

for England. London: DoH.

DIMERY L, PEREIRA S & REYNOLDS T. (2003) Observation and

Engagement: A Practice Development Study. National Mental Health

Nursing Conference: Partners in Practice and Education.

DIX R. (2001) Observation and technology: Logical progression or ethical

nightmare? National Association of Psychiatric Intensive Care Units

Bulletin: Practice Feature 1, 22-29.

FLETCHER RF. (1999) The process of constant observation:

perspectives of staff and suicidal patients. Journal of Psychiatric and

Mental Health Nursing 6, 9-14.


43

FOUCAULT M. (1975) Discipline and Punish: The birth of the prison.

London: Penguin.

GLOUCESTER MENTAL HEALTH PARTNERSHIP. (2002) The

Montpelier Unit, Low Secure Rehabilitation: Draft Handbook and

Operational Policy. Gloucester: Gloucester Mental Health Partnership

NHS Trust.

GREENWOOD J. (1984) Nursing research: a position paper. Journal of

Advanced Nursing 9, 77-78.

JONES J, LOWE T & WARD M. (2000) In-patients’ experiences of

nursing observation on an acute psychiatric unit: a pilot study. Mental

Health Care 4, 125-129.

MEIKLEJOHN C, HESMONDHALGH M & MASON-PENNY L. (2003)

Nursing observations in a medium secure unit: a review of practice.

Mental Health Practice 7 (3), 12-14.

NEWMAN T & HAYMAN S. (2002) Policing, Surveillance and Social

Control: CCTV and Police Monitoring of Suspects. Cullompton: Willan

Publishing.

PORTER S, MCCANN A & MCGREGOR KETTLES A. (1998) Auditing

suicide observation policies. Psychiatric Care 5 (1), 17-21.

REGULATIONS OF INVESTIGATORY POWERS ACT. (2000) London:

The Stationery Office.

ROSENHAN DL. (1973) Being sane in insane places. Science 179

(4070), 250-258.

ROYAL COLLEGE OF PSYCHIATRISTS. (1998) Guidance for

Videotaping. London: Royal College of Psychiatrists.

SHORT E & DITTON J. (1998) Seen and now heard: Talking to the

targets of open street CCTV. British Journal of Criminology 38 (3), 404-

425.


44

Appendix 1

Draft Guidelines and Procedures for Patient Observation

Introduction

Observation is not simply aimed at preventing harm by controlling patient

activity. It provides the healthcare professional with the opportunity to

engage in therapeutic exchange. Cardell and Pitula (1999) noted that

patients experienced observations as therapeutic if the staff involved

actively engaged them in the process.

Barker and Cutcliffe (1999) take the argument further, suggesting that

observation should be abandoned completely. They argue that it is used

because of organisations’ ‘fear of litigation’ and that it serves a useful

function by assuring the absent doctor of the physical safety of the

patient.

Procedure for

patient observations

• On admission, both a nurse and a doctor will assess patients (UKCC

1992, Severn NHS Trust 1995).

• Admitting staff will identify any risk behaviours relating to self, others

and self neglect and associated level of risk. This will involve

considering actual and clinical indicators. The levels of risk are

defined in the CPA (GMHS 1999) and should be utilised.

• The admitting nurse and doctor will jointly agree an initial level of

‘observation’ based on identified levels of risk.

• Where staff do not agree upon a level, then all efforts should be

made to negotiate an agreement. Ultimately the nurse in charge of

the ward is responsible for the Health and Safety of those within the

ward environment and therefore the immediate level of patients’

supervision.

• The named nurse once appointed will be responsible for ensuring

observation levels are regularly reviewed and recorded in the Unified

Care Plan. Normally reviews will take place during multi-

disciplinary/inter-professional meetings. Should a level of

observation prove to be counterproductive and in need of being

reduced, then the team should agree such a decision during a

handover period. All decisions and rationale should be recorded in

accordance with Trust and Unit risk-taking procedures.

• The evidence suggests that a MDT review should take place when

one-to-one observations have exceeded 72 hours (Shugar &

Rehaluk, 1990) as problems with behavioural escalation, secondary

gain for the patient and staff burnout may arise.


45

• The patient should be kept informed of their care plans and any level

of observation prescribed. In rare circumstances the team may make

a decision not to do so. The rationale for this decision should be

recorded.

• The nurse co-ordinating the shift is responsible for ensuring that

adequate resources are available for implementing observations

within the ward. Any unresolved staffing issues should be reported to

the head of nursing.

• Where 15 minute observations or higher (up to one-to-one) have

been prescribed then a supervision record should be maintained.

Once completed, the supervision record should be filed in the health

record. Any specific instructions should be recorded at the top of the

form.

• Ideally the nurse responsible for carrying out observations will know

the patient, the staff member will understand the patients. Nursing

care plans will include known risk factors and staff will have received

training in undertaking observations.

• Staff should not undertake one-to-one observations for longer than

two hours and ideally between 30 minutes and an hour. Staff should

then have a break from undertaking observations for at least an hour

(DOH 1999).

• There will be times when staff other than nursing will assume

responsibility for observing the patient e.g. occupational therapist. All

staff including nurses, other professionals and medical staff, should

have received training prior to undertaking ‘observations’.

• During night shifts, patients within the acute directorate, including the

Montpellier Unit, will be observed hourly. This is a minimum

standard. A number of units within other directorates are of a

residential or rehabilitative nature. Patients residing within those

units may have observations set at a lower level than this following

appropriate assessment of risk.

Levels of

observation and

their description in

the care plan

The Gloucestershire CPA defines risk into three categories: low, medium,

and high. For reasons of consistency, the table below contains

suggestions as to the range of observations levels that might be required

in response to the three levels of risk. It is important for staff to remember

that the observation levels listed in the table are only suggestions and do

not replace proper individual assessment. The specific observation level

will be determined from a detailed assessment of the patient and their

immediate situation.


46

Level of assessed risks Suggested level of supervision

Low risk

(little or no risk)

Knowledge of intended whereabouts, e.g. whilst on leave etc. up to

hourly checks at night.

Medium risk

(intermediate)

Half hourly checks up to 15 mins at nights or 15 mins when awake/30

mins at night.

High risk

(marked degree)

15 mins when awake/30 mins when asleep, up to 15 mins checks when

awake and asleep or randomised observations within 15 mins or 1:1

contact e.g. audible/visual or 1:1 contact (within physical reach).

The observation available for description within the care plan ranges from

one-to-one contact to no formal observations. When describing

observations in the care plan, the nurse should enter as much descriptive

detail as necessary to leave no doubt as to the exact observational

behaviour that is necessary by nurses who are carrying out the

observation. Useful terms for inclusion in the care plan may include:

• One-to-one visual contact within arms reach;

• One-to-one contact within easy distance of physical contact;

• One-to-one visual contact at all times;

• Five minute randomised observations;

• Ten minute randomised observations (this statement can then be

repeated at increasing five minute intervals as required by the

assessment).

Note: The phase ‘no formal observations within a care plan’ equates to:

• To know the intended whereabouts of a patient e.g. while out on

leave;

• To visually check at the start of each shift, drug round, lunch and

supper time;

• Hourly checks throughout the night.

Suggestions for

night-time

observations

The Montpellier Unit has the facility to use CCTV for night-time

observations between 11pm-7am, offering the patient an unobtrusive

approach which facilitates sleep. CCTV is not recorded and patients are

able to ascertain when cameras are on from the bedroom. CCTV will only

be used by healthcare professionals at prescribed observation times for

the minimum duration needed to establish need/intervention required.

• On admission patients will be offered the option of being observed

via CCTV or through traditional methods of night-time observation.

• CCTV and traditional methods will be explained and demonstrated to

the patient.

• Patient consent must be explicit before CCTV is used. If in doubt,

traditional methods will be used.

• Patient consent must be documented, signed and kept in the

patients’ notes.


47

Appendix 2

Draft Care Plan for Night-Time Observations

Date No. Problem Goal/Objective Intervention Evaluation Date Signed

Montpellier Unit has the facility to offer a choice of two methods of night-time observations.

1. CCTV can be used for night-time observations between 11pm-7am, offering the patient an unobtrusive approach, which facilitates sleep. CCTV can detect both movement and sound. CCTV is not recorded and patients are able to ascertain when cameras are on from the bedroom.

2. The traditional method of

opening the bedroom door and using a torch.

To allow the patient to have a choice of method used for night-time observation.

1. On admission patients will be offered the option of being observed via CCTV or through traditional methods of night-time observation.

2. CCTV and traditional

methods will be explained and demonstrated to the patient.

3. CCTV will only be used by

healthcare professionals at prescribed observation times for minimum duration needed to establish need/intervention required.

4. Patient consent must be

explicit before CCTV is used. If in doubt traditional methods will be used.

5. Patient consent must be

documented, signed and kept in the patients’ notes.

the appropriate use of closed circuit television (cctv...

Documents